Engaging Physicians in the Health

Care Revolution
Thomas H. Lee, MD
Chief Medical Officer,
Press Ganey

April 21, 2015

 Something Big Is Going On …
From New York Times (Page 1, Feb 18, 2015)

Recent NYT story on how

reduction of suffering is
becoming a goal around which
health care providers are
starting to organize themselves.

This is something different than

asking every clinician to work
hard.

It’s not asking clinicians to be

better people.

What is it about, and why is it

important?

And how do we accelerate

progress?

© 2015 Press Ganey Associates, Inc. 2

 What is Happening to Us is Historic in Nature

 We have a crisis in the reliability and the coordination of care -- throughout

the world

 Irresistible drivers of change include:

 Medical progress
 Aging population
 Global economy

 Challenges for providers and patients:

 Too many people involved, too much to do, no one with all the
information, no one with full accountability
 Result: Chaos  gaps in quality and safety, inefficiency
 Patients are afraid not just of their diseases, but of lack of coordination

Question: If somehow, magically, health care costs were not a

problem, would you say that health care is working just fine?

© 2015 Press Ganey Associates, Inc. 3

 Our Idealistic Aspirations and Our Business
Imperatives Are Converging

 Until recently, providers could

get by with hard work and a
good brand
 Get patients in the door
 Negotiate “cost-plus”
contracts
 Today, that approach is a
strategy of trying to be the last
iceberg to melt

© 2015 Press Ganey Associates, Inc. 4

 Our Idealistic Aspirations and Our Business
Imperatives Are Converging

 Until recently, providers could

get by with hard work and a
good brand
 Get patients in the door
 Negotiate “cost-plus”
contracts
 Today, that approach is a
strategy of trying to be the last
iceberg to melt

We are entering a new health care marketplace driven by competition on the

“right things”:
• Meeting patients’ needs
• Doing so as efficiently as possible
It’s challenging … but it is better than the alternatives, and it feels right.
© 2015 Press Ganey Associates, Inc. 5
 An Overall Strategic Framework

© 2015 Press Ganey Associates, Inc. 6

 A Six Component Framework

© 2015 Press Ganey Associates, Inc. 7

 What Do Patients Really Value?

All Patients
15.7%
Recommendation Failure Rate
19% of patients 81% of patients

Low: Confidence in Provider High: Confidence in Provider

74.6% Fail to Recommend 1.9% Fail to Recommend

14% of patients 5% of patients 8% of patients 72% of patients

Low: Worked Together High: Worked Together Low: Worked Together High: Worked Together
90% Fail to Recommend 28% Fail to Recommend 11% Fail to Recommend 1% Fail to Recommend

11.4% of patients 2.5% of patients 0.8% of patients 3.4% of patients 2.4% of patients 5.9% of patients 3% of patients 68.4% of patients

Low: High: Low: High: Low: High:

Low: High:
Listens Listens Concern for Concern for Concern for Concern for
Courtesy Courtesy
Carefully Carefully Worries Worries Worries Worries
92.8% Fail 78.2% Fail
45.7% Fail 24.7% Fail 22.3% Fail 6.3% Fail 5.6% Fail 0.6% Fail

High Risk Low Risk

© 2015 Press Ganey Associates, Inc.
8
 And Now for the Hard Part …

© 2015 Press Ganey Associates, Inc. 9

 Max Weber’s Four Models for Social Action

1. Tradition – e.g., Mayo Dress Code

2. Self-interest – e.g., Performance bonuses

3. Affection – e.g., Peer pressure

4. Shared purpose – e.g., Reducing suffering

• We need to press all four levers.

• But the first lever that must be pressed is creation of Shared
Purpose.
• In isolation, any of the other three levers is ineffective or
potentially perverse.
• But in pursuit of a shared purpose, all three other levers can
be embraced.

© 2015 Press Ganey Associates, Inc. 10

 My Introduction to “Suffering”

• March 2013 – breakfast with Pat Ryan

• My initial reaction (negative)
• Reaction of my physician colleagues at NEJM
(also negative)
• Comment by copy editors that NEJM does not
use the word suffering

© 2015 Press Ganey Associates, Inc. 11

 Suffering Is Measurable
Mitigatable Suffering Arising from Illness & Treatment: Avoidable Suffering Arising from Dysfunction:
Communication gaps, pain management, Lack of respect, lack of coordination and
responsiveness, anxiety teamwork, lack of privacy

Measure Description % Top % Sub- Measure Description % Top % Sub-

Box optimal Box optimal

How often did nurses explain things to you How often did nurses treat you with
75.2% 24.8% 85.8% 14.2%
in a way you could understand? (HCAHPS) courtesy and respect? (HCAHPS)
During this hospital stay, how often was your How well staff worked together to
64% 36% 70% 30%
pain well controlled? (HCAHPS) care for you (PG)
During this hospital stay, after you pressed Staff concern for your privacy (PG) 68.5% 31.5%
the call button, how often did you get help 64.8% 35.2%
as soon as you wanted? (HCAHPS)
How well did staff address your emotional
57.5% 42.5%
needs? (PG)
12
© 2015 Press Ganey Associates, Inc.
 Appreciative Inquiry as a Tool to Create Shared Purpose

 Focus on positive, not errors

 What went right? What characterizes the cases that made us
proud?
 Identify the features that characterize care at its best – and try to
make those things happen reliably.
 Deconstruct “great care” and focus organization on delivering it.
 Challenge to leadership:
– Describe vision for what lies on other side of change
underway.
– Make case that it is potentially good for patients and society,
perhaps even great, and more important than the agendas of
any of us as individuals

© 2015 Press Ganey Associates, Inc. 13

 Prospect Theory and Use of Financial Incentives

Perceived Gains

Losses Gains

Perceived Losses

Prospect Theory, Kahneman and Tversky, Econometria 1979

© 2015 Press Ganey Associates, Inc. 14
 Transparency: Screen Shot From University of
Utah Find-a-Doctor Site

© 2014 Press Ganey Associates, Inc. 15

 Patient Satisfaction
PROVIDERS AT 99TH %ILE OR ABOVE HOW DO WE
Transform
the system?

30%
25% 26%
COMMUNICATE
the need
25% for change
% of total providers

DEVELOP
your
20% teams
17% ESTABLISH
metrics

15% 13% ENGAGE

physicians
staff

10% and trainees

EMPOWER
front-lines

5% 3% NURTURE
1% a culture of
0% continuous
2009 2010 2011 2012 2013 2014 innovation
*All Facilities Database includes the following
Number of Physicians: 142,411
Number of Patients: 2,783,597 © Vivian S. Lee, 2014
 And the number of dollars that U of Utah
physicians have in incentives for improving
patient experience is …
 And the number of dollars that U of Utah
physicians have in incentives for improving
patient experience is …

$0
 Advice From a Different Type of Doctor

 “Being a professional is doing

the things you love to do, on the
days you don't feel like doing
them.”
-- Julius Irving (“Dr. J”)

• Our challenge – can we create

a context in which our colleagues
live up to their own aspirations for
the care we are delivering on every
single patient?

© 2015 Press Ganey Associates, Inc. 19

 Conclusions

 We know what we need to do – organize care for real

competition:
– Meet patients’ needs – reliably
– Do so efficiently
• We know how to do it.
– Create shared vision
– Measure
– Create and support teams
– Use other Weber models for social action, including
transparency

© 2015 Press Ganey Associates, Inc. 20